Safe Schools NC is a statewide partnership of organizations and individuals dedicated to eliminating bullying, harassment, and discrimination on the basis of actual or perceived sexual orientation and gender identity in North Carolina Schools.

Contact Information for person reporting the incident *( indicates required field)** (Please provide your contact information if you would like someone from our organization to contact you regarding this incident)
First Name
Middle Name
Last Name
Address
City
State
Zip
Phone Number (xxx) xxx-xxxx
Date of Birth (mm/dd/yyyy)
*Name of School
*Are you completing this incident report for yourself or on behalf of someone else?
If reporting for someone else, please enter his/her name and your relationship to this person.	His/Her Name:
	Relationship To Me:

Incident Basics
Date of Incident (mm/dd/yyyy)
Location of the Incident
Time of the Incident

*Description of the Incident
Please fully describe what occured, who was involved and how it made you feel.


Incident Details
*Is this the first time the incident has occured (in general)?
*Is this the first time the incident has occured with the same indvidual(s)?
If you answered no to the question above, how many other times has this type of incident occured with this individual(s)?
*Did any school teacher or administrator witness the incident?
*Have you reported this incident to anyone else?
If so, to whom and what help if any have you received?

** This incident report was created in collaboration with GLSEN Winston Salem


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